Simplified Outpatient

Documentation
and Coding
Reduce Workload With Recent Updates To
E/M Coding and Team Documentation

Jill Jin, MD, MPH, FACP Jeannine Engel, MD, MACP Kevin Hopkins, MD
Clinical Assistant Professor, Associate Professor, University of Primary Care Medical Director,
Northwestern University Feinberg Virginia School of Medicine West Region, Cleveland Clinic
School of Medicine Community Care

How Will This Toolkit Help Me?

Learning Objectives

1 Describe the most recent billing and coding documentation guidelines

2 Implement workflow solutions for more efficient documentation

3 Provide examples of documentation to help educate physicians and their teams

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 1
 Introduction
Physicians and supporting team members in medical practices are experiencing
burnout at an unsustainable rate. An unmanageable workload, in large part due to
the electronic health record (EHR) documentation burden, contributes to physician
burnout. Furthermore, a physician sitting at a computer performing the clerical task
of data entry and note-taking is a low-value use of a high-dollar resource.

Physicians and advocacy groups have been asking to reduce regulatory requirements
for less-meaningful work for the past decade. In recent years, there have been 2 major
favorable changes in regulation to decrease documentation burden and redundancy
for physicians during ambulatory visits:

1. J anuary 1, 2019 (PDF): allowing ancillary staff members to document certain parts of the clinical note that physicians
can then review and verify, rather than independently re-document1

2. J anuary 1, 2021: changing level of service (LOS) codes to only depend on medical decision-making or time, not
history or physical exam elements2

These changes recognized duplication in data collection and recording, helped clarify billing rules, and removed
specialty‑specific challenges created by the previous guidelines that had been in use for a quarter of a century. While
it seemed intimidating to many physicians to understand yet another set of rules, most practicing clinicians agree that
these changes “made sense” and made their lives easier because no substantial requirements were added, and many
requirements were removed.

Four STEPS to Optimize Documentation and

Coding Strategies in Your Practice
1. Understand Current Guidelines and How They Benefit You

2. Engage Key Players

3. Educate Physicians and Other Team Members

4. Develop Team Documentation Workflows

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 2
 1 U
 nderstand Current Guidelines and How They
Benefit You
2019 Changes
In 2019, significant and welcome changes were made to the existing documentation guidelines.1 These changes
began addressing unnecessary redundancy in medical charts. Now, physicians can use the documentation
of history performed by other clinical team members (eg, medical assistants and nurses) and non-clinical
documentation assistants (eg, clerical staff, scribes, students, or patients themselves) for billing requirements.
You can find more information on this process in the AMA STEPS Forward® Team Documentation toolkit.

2021 Changes
In 2021, changes to the Current Procedural Terminology (CPT®) Evaluation and Management (E/M) codes went
into effect.2 This upgrade affected all new (99201-99205) and established (99211-99215) outpatient visit billing
standards. Only the medically necessary and appropriate portions of history (including the Review of Systems)
and physical exam are required, thus reducing documentation burden.

In other words, determination of the appropriate level of service no longer includes history and physical
exam documentation but rather depends only upon either medical decision making (MDM) or the total
amount of time spent providing care for a patient on the day of the visit (including before and after the
visit, not just face-to-face time)—see Table 1.

Table 1. Overview of CPT® E/M Coding

CPT® New Established New Established New Established New Established

99202 99212 99203 99213 99204 99214 99205 99215
Time (min) 15-29 10-19 30-44 20-29 45-59 30-39 60-74 40-54
MDM Straightforward Low Moderate High

History Medically appropriate Medically appropriate Medically appropriate Medically appropriate

Exam Medically appropriate Medically appropriate Medically appropriate Medically appropriate

Another important addition is the prolonged service codes when billing

based on time:

• F or non-Medicare payers, the physician can add 1 or multiple 15-minute

prolonged service codes (99417) when a visit is billed based on time and
they have exceeded the total time associated with the highest level of
service (99205 or 99215).

• F or Medicare patients, the physician can add the G2212 code for each
prolonged 15-minute interval. However, the minimum time required to use
the prolonged service code differs from non-Medicare payers—see Table 2.

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 3
 Table 2. New Prolonged Service Codes When Billing Based on Time2

Time Spent
Non-Medicare Medicare
Standard Level 5 Standard Level 5
(60-74 min) 99205 (60-88 min) 99205

New Prolonged Prolonged

(75-89 min) add 99417 (89 -103 min) add G2212
Patient
Extra prolonged add additional 99417 Extra prolonged add additional G2212
(90 or more min) codes as needed for each (104 or more min) codes as needed for each
15-minute interval 15-minute interval

Standard Level 5 Standard Level 5

(40-54 min) 99215 (40-68 min) 99215

Established Prolonged Prolonged

(55-69 min) add 99417 (69-83 min) add G2212
Patient
add additional 99417 add additional G2212
Extra prolonged codes as needed for each Extra prolonged codes as needed for each
(70 or more min) 15-minute interval (84 or more min) 15-minute interval

Q&A

Do these changes only affect primary care or other specialties too?

These changes are for the service codes themselves, affecting any specialty that bills these service codes.

Should I delete the history and physical sections of my notes?

Documentation of the history and physical examination are still important for excellent patient care.
However, they are no longer a requirement for determining level of coding.

Has anything changed with the Level of Service codes themselves? For example, is a Level 4 Established
Patient (99214) visit still a Level 4?

For the most part, if the service you provided was a Level 4 service before, it is a Level 4 service now based
on MDM. The difference is that you should not have to document certain “required” elements such as PE or
ROS to get your documentation to a certain level of service. Now, the Level of Service is based on the total
time or MDM only.

Why is there a difference between Medicare and non-Medicare prolonged service times?

When CPT® wrote the description for the prolonged service code, they used the following language:

“Code 99417 is only used when the office or other outpatient service has been selected using time alone as
the basis and only after the minimum time required to report the highest-level service (i.e., 99205 or 99215)
has been exceeded by 15 minutes. To report a unit of 99417, 15 minutes of additional time must have been
attained. Do not report 99417 for any additional time increment of less than 15 minutes.” 3

CMS disagreed with the minimum time requirement. They felt that the prolonged service code should be
added to the maximum time interval for the base service, so they finalized their own prolonged service code,
G2212, with a different base time requirement.

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 4
 Is there a limit to the number of prolonged service codes I can add?

There is no limit to the number of 15-minute prolonged service codes that can be added.

Do I have to document time spent on each task (eg, chart review, documentation, talking to a patient),
or just total time?

The 2021 guidelines do not provide specific documentation best practices for reporting time; however, the
primary goal of documenting time is to ensure an accurate record of the total time spent on patient care
on the date of the encounter.

How do patients’ social determinants of health (SDOH) affect coding?

Social determinants of health can contribute to the complexity of patient issues and, as a result, may affect
both the time spent during an encounter coordinating care and the level of MDM. Getting in the habit of
adding any ICD-10 SDOH diagnoses on the claim being used in MDM will demonstrate the SDOH impact.
These ICD-10 SDOH diagnoses will also help support medical necessity for higher levels of service. Examples
of SDOH Z codes can be found in this infographic from CMS (PDF).

Here is an example of an EHR shortcut to document SDOH issues:

Patient’s care may be negatively impacted by

{SDOH list shortcut}. Based on these, patient will List shortcut drop-down menu options
not be able to ***. housing inadequacy/insecurity
food insecurity
poverty
access to care
medical literacy
incarceration
environmental conditions
quality of housing
***

Are tests counted for the data component of MDM when they are ordered or resulted?

The data component of MDM includes the thought processes for diagnosis, evaluation, or treatment. Any
ordered test is presumed to be analyzed when it results; therefore, the test is counted in the encounter
when it was ordered. Tests ordered outside of an office visit (eg, with pre-visit labs) may be counted in the
encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in
the encounter when it is analyzed.

2  ngage Key Players

E
Many organizations have not yet applied these new time-saving billing and coding changes because of the
strain and distraction of the COVID-19 pandemic. However, because of the pandemic toll on physicians, it is more
important than ever before to reduce unnecessary burdens.

Any change in workflow, particularly if there is any association with licensure or accreditation, must be
approached with the involvement of the key players (Figure 1).

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 5
 Figure 1. Key Players to Engage

Compliance Officer
Your compliance office needs to work closely with you to plan and implement these new rules.
A compliance officer or department is responsible for ensuring you and your organization
operate within the regulatory guidelines of federal, state, and local authorities.

Revenue Cycle Management Billing and Coding Experts

Your revenue cycle billing and coding experts are likely auditing your charts and adjusting charges as needed behind the
scenes. Billers and coders in most healthcare organizations are further removed from the point of care delivery than they
might prefer, making it challenging for them to provide the level of support that could benefit clinical teams. Reach out to
them early in the process to leverage their knowledge.

Information Technology (IT) and Health Information Management (HIM) Teams

Your IT and HIM teams can optimize changes, so you work smarter, not harder. They can “turn on” access to the medical
record for ancillary staff and patients. Often these elements of history are entered by team members but not accessible
to the physician, leading to duplication of work. Some EHR systems have embedded tools that support billing and coding
documentation requirements. Examples include Level of Service (LOS) selection support, a Medical Decision Making (MDM)
calculator, and system links or phrases to easily document the amount of time spent on various care-related tasks.

Clinician Champions or Clinical Documentation Improvement Specialists

An interested physician who is knowledgeable about the documentation workflow and how the medical record works for
clinicians is an asset. Provide relative value unit (RVU) support or protected time for this important work for themselves
and their peers.

Operations and Nursing Leadership

It is imperative to involve operations leadership and nursing leadership early on, particularly if you plan to have medical
assistants or nurses perform any new tasks related to documentation of patient encounters. Work with practice managers
and nursing education to develop any training and competencies needed to prepare team members for new responsibilities.
Adding documentation responsibilities will require buy-in from those who supervise the ancillary team members (eg,
practice managers) and assurance that those care team members will not be asked to perform duties beyond their training
and scope.

3 E
 ducate Physicians and Other Team Members
The 2021 CPT E/M documentation guidelines for billing represent the most significant changes in how clinicians
code visits since 1995. In light of this, practices and organizations should dedicate considerable time and effort to
educating physicians, advanced practice providers (APPs), and other clinical team members about the updates.
This training should be valued and provided during regular hours. Providing compensation and/or blocking time
to attend is critical.
Consider which opportunities and settings would be best for sharing the important content and how the
individuals on your team learn most effectively. Sending a mass email with all the information may take less time
than a group learning session followed by individual, at-the-elbow support. However, it is also less likely to bring
about the desired transformation.
Taking the time to explain the individual and practice-wide benefits of the revised documentation requirements,
particularly those related to reducing redundancy and “note bloat,” will likely lead to greater clinician interest
and adoption. Using clinical vignettes, such as those provided as part of this toolkit, is often the most
effective way of sharing this information with clinicians. Additionally, continue to provide easy access to billing
and coding support within the organization for questions.
Use the following clinical vignettes to help clinicians understand how to use the updated CPT coding guidance.

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 6
 Clinical
Clinical Vignette
Vignette 1. Sample
1. Sample Progress
Progress Note,
Note, Level
Level 4 MDM
4 MDM

HPI
60 y/o male here for follow up HTN and HL.
Doing well, no complaints.
Meds reviewed.
See A/P for remainder of HPI.

PEX

Vital signs: normal including blood pressure - 120/72

Heart: RRR, no murmurs
Lungs: clear to auscultation

A/P

1. H
 TN - well controlled on lisinopril 20 mg and thiazide diuretic 25 mg daily. Continue current medications.
2. H
 L - on atorva 20 mg daily. No side effects. Last lipid panel 6 mo ago at goal. Continue current treatment.
Next visit in 6 mo for follow up and wellness check.

Notes for the coding and documentation exercise:

Each element (number of diagnoses, complexity of data, and risk) can be classified as straightforward, low, moderate,
or high.
For CPT coding, 2 of 3 MDM elements need to meet the moderate level to be considered Level 4 MDM.

Number of Diagnoses Complexity of Data Risk CPT Code

This case meets criteria This case meets criteria for This case meets criteria for This case meets Level 4
for moderate number straightforward complexity moderate risk of morbidity criteria for number of
of diagnoses of data (minimal or no data) from additional diagnostic diagnoses and risk
(any criteria below met) testing or treatment

≥ 1 chronic condition Example:

with exacerbation
 rescription medication
P
≥ 2 stable chronic management
conditions (can be prescribing new
medication, continuing
1 acute illness or injury same dose of current
with systemic symptoms medication, or changing
dose of current
1 acute illness or injury medication)
with uncertain prognosis

Moderate/99214 Straightforward/99212 Moderate/99214 OVERALL CODE: 99214

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 7
Clinical Vignette
Clinical 2. 2.
Vignette Sample Progress
Sample Note,
Progress Level
Note, 4 MDM
Level 4 MDM

HPI
40 y/o female with diet-controlled diabetes and obesity presents to establish care after moving
from another state. No meds. States she had a visit with her old PCP about 6 mo ago, and blood work was done at
that time.
Currently living with her cousin while looking for jobs. She is a single parent to 2 teenagers. She has not found many
grocery stores in the neighborhood and is not comfortable with public transportation. She sometimes can borrow a
car from her cousin, but mostly uses this for job hunting, or transporting her children to school events. Asks to defer
lab testing until her next visit due to possible out-of-pocket costs.

PEX
BP 120/72 P 74 BMI 35.12

A/P
1. D
 iet-controlled DM. States had labs done 6 mo ago, does not recall last A1c. Will work on transfer of records and
defer testing until next visit.
2. O
 besity - discussed daily exercise, adding more vegetables to her diet.
3. S DOH - Patient's care may be negatively impacted by food insecurity due to her current lack of income. Based
on this, patient will not be able to access healthy foods to manage her diabetes and obesity. Will consult SW for
community resources and social support.

Notes for the coding and documentation exercise:

Each element (number of diagnoses, complexity of data, and risk) can be classified as straightforward, low,
moderate, or high.
For CPT coding, 2 of 3 MDM elements need to meet the moderate level to be considered Level 4 MDM.

Number of Diagnoses Complexity of Data Risk CPT Code

This case meets criteria This case meets criteria This case meets criteria for This case meets Level 4
for moderate number for minimal complexity of moderate risk of morbidity criteria for number of
of diagnoses data (minimal or no data) from additional diagnostic diagnoses and risk
(any criteria below met) testing or treatment

≥ 1 chronic condition Example:

with exacerbation
 iagnosis or treatment
D
≥ 2 stable chronic significantly limited by
conditions social determinants
of health
1 acute illness or injury
with systemic symptoms

1 acute illness or injury

with uncertain prognosis

Moderate/99204 Straightforward/99202 Moderate/99204 OVERALL CODE: 99204

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 8
Clinical Vignette 3. Sample Progress Note, Level 5 MDM

HPI
63 y/o male with 5 days of worsening cough productive of yellow sputum, SOB, and wheezing, as
well as temp to 100.4 at home.
Hx COPD on daily LABA and inhaled steroid, former smoker, not on home oxygen. Last visit with me 2 mo ago for
routine follow up - stable at that time. Most recent PFTs showed FEV1 55% of predicted. He has been hospitalized 2
times in the past 2 years for COPD exacerbation.
No known sick contacts, had a negative covid PCR test yesterday. Has been using albuterol rescue inhaler 3-4 times
daily for the last 2 days.

PEX
VS - O2 sat 90% on RA, baseline is 92-94%
other VSS and unchanged from baseline
CV - RRR
Lungs - fair air movement, diffuse inspiratory and expiratory wheezes

A/P
 OPD exacerbation with possible pneumonia - albuterol neb given in clinic. He felt a bit better, but O2 sat still lower
C
than baseline. Discussed directly admitting him to observation status, but he is adamant about returning home.
Will rx Prednisone 40 mg daily for 5 days, first dose today, as well as oral antibiotics.
Follow up in clinic in 2 days, stressed need to go to ED if worsening symptoms; he understands and agrees.

Notes for the coding and documentation exercise:

Each element (number of diagnoses, complexity of data, and risk) can be classified as straightforward, low,
moderate, or high.
For CPT coding, 2 of 3 MDM elements need to meet the high level to be considered Level 5 MDM.

Number of Diagnoses Complexity of Data Risk CPT Code

This case meets criteria This case meets criteria for This case meets criteria This case meets Level 5
for high number minimal complexity of data for high risk of morbidity criteria for number of
of diagnoses (minimal or no data) from additional diagnostic diagnoses and risk
(any criteria below met) testing or treatment

≥ 1 chronic condition with Example:

severe exacerbation
 ecision regarding
D
hospitalization
1 acute illness or injury
with threat to life or
bodily function

High/99215 Straightforward/99212 High/99215 OVERALL CODE: 99215

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 9
Clinical Vignette 4. Sample Progress Note, Level 5 Time-Based

HPI

48 y/o female with T2DM and migraine HA here for routine f/u - last visit with me 3 mo ago.
Not doing well today. Tearful. States teenage son having difficulties in school and she just found out 2 wks ago that
he may be using illegal drugs. Her husband has not been coping well and has increased his alcohol consumption.
She is working with the school counselor and other resources for her son. She cannot sleep and this is making
her feel very anxious and emotionally labile, crying frequently and having difficulty functioning at home and at
work. Weight is stable. Denies SI/HI. Has never experienced symptoms like this in the past - has never been on
prescription medications for depression or anxiety.
PHQ9 - 10 points (moderate depression)
GAD7 - 12 points (moderate anxiety)

A/P
1. M
 ood disorder, mixed depression/anxiety, reactive. Start sertraline 25 mg, increase to 50 mg in 1 week. Refer to
crisis counseling via social work. I personally spoke with Dr. Smith, PhD who can see her in 1 week. She contracted
for safety.
2. T
 ype 2 Diabetes with peripheral neuropathy. Continue current medications. BG running in 150-180 range at
home. Lab testing deferred to next visit.
3. M
 igraine HA. Stable.
F/u in 3 weeks.
My total time on this date and for this encounter was 60 minutes which included the following activities: preparing
to see the patient, performing a medically appropriate examination and/or evaluation, counseling and educating
the patient/family/caregiver, ordering medications, tests, or procedures, referring to and communicating with
other health care professionals about management, and documenting clinical information in the electronic or
other health record. This time is independent and non-overlapping.

Notes for the coding and documentation exercise:

Each element (number of diagnoses, complexity of data, and risk) can be classified as straightforward, low,
moderate, or high.
For CPT coding, 2 of 3 MDM elements need to meet the high level to be considered Level 5 MDM. Alternatively,
time-based coding can qualify gor Level 5 independent of MDM.
Number of Diagnoses Complexity of Data Risk CPT Code
This case meets criteria for This case meets criteria for This case meets criteria for This case meets Level 4
moderate number of diagnoses moderate complexity of data moderate risk of morbidity criteria for number of
(any criteria below met) (any criteria below met) from additional diagnostic diagnoses and risk
testing or treatment
≥ 1 chronic condition  ny combination of 3: review
A This case meets Level
with exacerbation notes, review test, order test, Example: 5 criteria for time
independent historian (other (40 minutes) PLUS
≥ 2 stable chronic than patient)  rescription medication
P an additional 99417
conditions management prolonged service code
Independent interpretation (can be prescribing new (15-minute)
1 acute illness or injury of tests medication, continuing
with systemic symptoms
 iscuss case with external
D same dose of current
1 acute illness or injury physician/qualified medication, or changing
with uncertain prognosis health professional about dose of current
management or test medication)
interpretation
MDM CODE: 99214
Moderate/99214 Moderate/99214 Moderate/99214
TIME CODE: 99215 + 99417

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 10
 DOWNLOAD
Clinical Vignette Packet
Use this handout of clinical vignettes during in-person training sessions


4 Develop Team Documentation Workflows

In many practice settings, the physician has historically written most, if not all, of the progress note and entered
information into discrete data fields in the EHR while also placing all the orders associated with the visit. A
common myth is that CMS or the Joint Commission requires the physician to document all components of
E/M services; however, this is not true. Now that you and your team understand the rules and have practiced
using them, it’s time to work together to complete documentation associated with patient encounters. Team
documentation is a cornerstone of efficient documentation and effective team-based care.

You can find detailed definitions and workflows in the AMA STEPS Forward Team Documentation toolkit.

Q&A

Where do I begin with team documentation?

You might start with licensed or certified team members already working in your practice, such as MAs or RNs.
For example, the MA doesn’t need to stop at the chief complaint. Medical assistants can also complete the
history of present illness (HPI), past medical history (PMH), social history (SH), and family history (FH) before the
physician reviews and verifies.

Once your existing team contributes directly to the chart, consider expanding who can contribute, especially if
your current team is unable or the practice is short-staffed. Ancillary staff such as transcriptionists, health care
undergraduate students, and medical students can be a great source of assistance when appropriately trained.
Learning team documentation is a great experience for medical students.

What about patient-entered data?

In some ways, the most important person on the team is the patient. No one knows their history better. With a
template (eg, timing, location, etc.), many patients can provide a detailed history, including answering prompts a
physician would ask as part of a differential diagnosis.

An increasing number of practices and health systems utilize their EHR’s patient portal to have patients review,
update, and add information to their own medical record. Patients can use the patient portal to update personal
demographic data, review medications and problem lists, and answer questions related to the History of Present
Illness (HPI) and Social Determinants of Health (SDOH), among other things. In some instances, EHR functionality
can automatically link patient-entered information to progress notes and other encounter documentation,
helping complete clinical documentation—many health organizations are working towards this goal.

Conclusion
Two fundamental changes to practice that can decrease documentation burden for
physicians are to:
1. Minimize unnecessary documentation by understanding current E/M coding requirements
2. Share the necessary documentation by implementing team documentation workflows
These changes enable physicians to give more of their undivided attention to patients while
decreasing their after-clinic charting time.

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 11
 AMA Pearls
• T
 he 2021 E/M changes took away many unnecessary documentation requirements and are considered a “win” for
physicians in the ambulatory setting

• Start by cleaning up your note templates to reduce note bloat and time spent on unnecessary documentation

• T
 raining medical assistants or other non-clinical staff to participate in team documentation is an additional key to
increasing documentation efficiency

Further Reading
Journal Articles and Other Publications
• American Medical Association. Table 2 ― CPT E/M office revisions level of medical decision making (MDM). Accessed June 8,
2022. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

• Millette KW. Coding Level 4 office visits Using the new E/M guidelines. Fam Pract Manag. 2021;28(1):27-33. https://www.
aafp.org/pubs/fpm/issues/2021/0100/p27.html

• Centers for Medicare and Medicaid Services. Evaluation and Management Services Guide. MLN006764. February 2021.
Accessed June 8, 2022. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/
downloads/eval-mgmt-serv-guide-icn006764.pdf

• Schuman AJ. Coding basics: medical decision making is key. Contemporary Pediatrics. October 1, 2018. Accessed June 7,
2022. https://www.contemporarypediatrics.com/view/coding-basics-medical-decision-making-key

• Jin J, Reimer J, Brown M, Sinsky S. Saving time playbook. AMA STEPS Forward®. 2021. Accessed June 8, 2022. https://www.
ama-assn.org/system/files/ama-steps-forward-saving-time-playbook.pdf

Online Resources
• American Medical Association. Need coding resources? Accessed June 6, 2022. https://www.ama-assn.org/practice-
management/cpt/need-coding-resources

• American Medical Asssociation. CPT (Current Procedural Terminology). Accessed June 6, 2022. https://www.ama-assn.org/
amaone/cpt-current-procedural-terminology

• American Medical Association. CPT® evaluation and management. Updated March 9, 2021. Accessed June 8, 2022.
https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

• American Academy of Professional Coders. 99202-99215: office/outpatient E/M coding in 2021. Last reviewed January 15,
2021. Accessed June 8, 2022. https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx

• American Academy of Family Physicians. Coding for Evaluation and Management services. Accessed June 8, 2022. https://
www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management.html

• Centers for Medicare and Medicaid Services (CMS). CMS-1734-F (Revisions to Payment Policies under the Medicare
Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2021). Accessed June 8, 2022.
https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1734-f

© 2023 American Medical Association. All rights reserved. SIMPLIFIED OUTPATIENT DOCUMENTATION AND CODING 12
• Sinsky CA, Basch P, Brown MT, et al. Electronic health record optimization: strategies for thriving. AMA STEPS Forward®.
August 30, 2018. Accessed June 8, 2022. https://edhub.ama-assn.org/steps-forward/module/2702761

• Rice J, Lozovatsky M, Hopkins K. Patient portal optimization: empower patients as partners in health care. AMA STEPS
Forward®. June 25, 2020. Accessed June 8, 2022. https://edhub.ama-assn.org/steps-forward/module/2767762

Disclaimer
AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the
time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice.
Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward®
content provides information on commercial products, processes, and services for informational purposes only. The AMA
does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS
Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties
of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind
arising out of use, reference to, or reliance on AMA STEPS Forward® content.

References
1. Centers for Medicare and Medicaid Services. Medicare Program; Revisions to Payment Policies Under the Physician Fee
Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment
Program; Medicaid Promoting Interoperability Program; Quality Payment Program—Extreme and Uncontrollable
Circumstance Policy for the 2019 MIPS Payment Year; Provisions From the Medicare Shared Savings Program—
Accountable Care Organizations—Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment
of Opioid Use Disorder Under the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment
(SUPPORT) for Patients and Communities Act. Fed Regist. 2018;83(226): 59452-60303. Codified at 42 CFR §405, §410, §411,
§414, §415, §425, and §495. https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf

2. American Medical Association. CPT® Evaluation and Management (E/M) office or other outpatient (99202-99215) and
prolonged services (99354, 99355, 99356, 99417) code and guideline changes. January 1, 2021. Accessed May 27, 2022.
https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

3. American Medical Association. AMA CPT® 2021 Professional Edition. American Medical Association; 2020.

About the AMA Professional Satisfaction and Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group is committed to making the patient–physician
relationship more valued than paperwork, technology an asset and not a burden, and physician burnout a thing of the past.
We are focused on improving—and setting a positive future path for—the operational, financial, and technological aspects
of a physician’s practice. To learn more, visit https://www.ama-assn.org/practice-management.

From the AMA STEPS Forward® Toolkit series: Simplified Documentation and Coding, v 4.0. Last updated 2023-11-29.

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